Malignant Pleural Effusion

American Thoracic Society

PATIENT EDUCATION | INFORMATION SERIES

Malignant Pleural Effusion

A malignant pleural effusion (MPE) is the build up of fluid

and cancer cells that collects between the chest wall and

the lung. This can cause you to feel short of breath and/or

have chest discomfort. It is a fairly common complication

in a number of different cancers.

CLIP AND COPY

What is the pleural space?

Both the lungs and the chest wall are lined with thin

membranes called ¡®pleura¡¯. The lung is typically fully

expanded in the chest and comes right up to the chest

wall. As such, the normal ¡®pleural space¡¯ (the area in

between the lung and the chest wall) only contains a

small amount of fluid (approximately 1 teaspoon).

What is a pleural effusion?

A pleural effusion is an abnormal build-up of fluid in the

pleural space.

What causes a pleural effusion?

A pleural effusion can be caused by many diseases. It can

be seen in infections and other diseases in addition to

various cancers. In general, fluid builds up in the pleural

space if there is an overproduction of fluid, decreased

absorption of the fluid, or both. If the cause of the

effusion is due to cancer cells in the fluid, the effusion is

called a ¡°malignant pleural effusion¡± or MPE.

What causes a malignant pleural effusion (MPE) to form?

An MPE forms when cells from either a lung cancer or

another type of cancer spread to the pleural space. These

cancer cells increase the production of pleural fluid and

cause decreased absorption of the fluid.

Who can get a malignant pleural effusion?

People with lung cancer, breast cancer, and lymphoma

(a cancer of lymphatic tissue) are most likely to get a

MPE. Mesothelioma (a rare cancer of the pleura itself)

is another common cause of MPE. Other causes of MPE

include cancer that has spread from the stomach, kidney,

ovaries, and colon.

What are the symptoms of a malignant pleural effusion?

The symptoms of a MPE can be extremely variable

and range from having no symptoms in some people

to being very bothersome in others. Below is a list of

common symptoms:

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Shortness of breath at rest or with activity

Chest pain or pressure

Cough

Pain when taking a deep breath, or the feeling of not

being able to take a deep, satisfying breath

Fever

Fatigue

How do you know if you have a MPE?

Your healthcare provider may first suspect that you have

a MPE on physical examination. To see if you have a MPE

and estimate how much fluid is present, you will have one

or more of the imaging tests:

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Chest X-Ray: A picture showing a view of the chest,

including the heart and lungs.

CT Scan of the Chest: Multiple pictures of the chest

(think of it as a set of bread-loaf slices through the

chest) that gives a lot more detail and information than

a chest X-ray.

Ultrasound of the Chest: One of the best methods of

imaging the pleural space. Ultrasound does not involve

any radiation and can also be used to help guide

procedures to sample or drain pleural fluid.

When a pleural effusion is suspected or confirmed , your

healthcare provider will need to take a sample of the fluid

to see what is causing the effusion. This can be done in one

of two ways.

¡ö Thoracentesis: This is a simple and safe procedure that

is often done in an outpatient setting. Usually you will

be sitting up and leaning over a table. The procedure

is done using local anesthesia medicine to reduce any

discomfort or pain. Ultrasound is often used to identify

a safe place to insert a catheter. The fluid is drained over

several minutes and the catheter is removed. At the end

Am J Respir Crit Care Med Vol. 194, P11-P12, 2016

Online version updated April 2021

ATS Patient Education Series ? 2016 American Thoracic Society



American Thoracic Society

PATIENT EDUCATION | INFORMATION SERIES

¡ö

of the procedure, a bandage is placed over the wound

which then closes on its own without the need for

stitches. The fluid is tested to determine the cause of the

effusion and look for cancer cells. (For more information

see the ATS Patient Information Series ¡°Thoracentesis¡±

fact sheet at patients.)

Thoracoscopy with biopsy: This is a slightly more

invasive procedure that is generally done for one of

several reasons:

? if a thoracentesis does not tell your healthcare

provider the cause of the effusion.

? if more tissue is needed to look for ¡®molecular

markers¡¯. This will help your oncologist select the

best medications to treat the cancer.

? to do a ¡®pleurodesis¡¯ (a procedure used to get the

lung to stick up to the chest wall¡ªsee below).

Thoracoscopy (often referred to as VATS¡ªvideo assisted

thoracoscopic surgery or ¡®medical pleuroscopy¡¯) is done

under moderate sedation or general anesthesia. Your

physician will make a small incision on your side between

the ribs, the fluid is drained out of the space and a camera

is inserted into the chest cavity to visually examine the

pleura and take biopsies to send for analysis under a

microscope. In certain cases, this can be performed as an

outpatient procedure, however your healthcare provider

may want to have you stay in the hospital for at least one

day observation.

How are malignant pleural effusions treated?

Medical oncologists (specialists who treat cancer) and

radiation oncologists may treat the underlying cancer

with chemotherapy, immunotherapy and/or radiation

to prevent the fluid from accumulating. Your lung doctor

(pulmonologist) or thoracic (chest) surgeon will work with

your oncology team to discuss several other treatments

currently available to remove the fluid and/or prevent it

from re-accumulating (building back up) with the goal

of keeping you breathing well. Your healthcare providers

will work together to both treat the cancer and treat your

symptoms.

Thoracentesis: The same procedure described above can

be used to drain the fluid completely.

Pleurodesis: This is a procedure where a chemical is

instilled into the chest cavity after the pleural fluid has

been drained to help get the lung to stick up to the chest

wall and reduce the risk of new build-up of fluid. This

procedure can be done either by placing a small catheter

between the ribs into the fluid and instilling a chemical

through the tube or by thoracoscopy (as described above)

and spraying the chemical onto the inside of the chest

wall in the pleural space. You will need to stay in the

hospital with a chest tube in place for a few days. The

main advantage of this approach is to hopefully prevent

future fluid build-up. You may have a temporary drop in

your oxygen level and you may need medicine for some

pain for a few days.

Indwelling pleural catheter (IPC): This device is a small

catheter that is placed under your skin and into the

pleural fluid, which allows repeated drainage at home

(without any more needle sticks) to relieve symptoms.

These catheters are placed using local anesthesia as an

outpatient procedure. The catheter is safe, easy to use

and may help allow the lung to eventually expand fully

up to the chest wall. Once the fluid build-up resolves,

the catheter can be removed in many patients after 2-3

months. The main disadvantage of the IPC is the need to

care for the catheter (which is not that difficult). For more

information, see the ATS Patient Information Series fact

sheet on indwelling pleural catheters at .

Authors: Roy Semaan MD, David Feller-Kopman MD,

Christopher Slatore, MD, MS and Marianna Sockrider, MD, DrPH

Reviewer: Charles Powell, MD, Rosemary Adamson, MBBS

R

Action Steps

? Malignant pleural effusions are a common complication

in some forms of cancer.

? If you have breathing problems with cancer, talk to your

healthcare provider to see if you have developed a MPE.

? Your cancer specialist will help you decide what the best

approach may be for you to treat the symptoms of MPE

and decrease the chance of it coming back.

Healthcare Provider¡¯s Contact Number:

Additional Resources:

American Thoracic Society

? patients/

(American Society of Clinical Oncology)

?

National Cancer Institute

?

Canadian Cancer Society

?

This information is a public service of the American Thoracic Society.

The content is for educational purposes only. It should not be used as a

substitute for the medical advice of one¡¯s health care provider.



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